EKGs Flashcards
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Normal Sinus Rhythm
This is normal sinus rhythm. For normal sinus rhythm, the rhythm will be regular, and the rate will be 60-100/min. A P-wave will come before each QRS complex. The PR interval will be normal (0.12-0.20 sec), and the width of the QRS complex will typically be normal (0.06-0.10 sec).
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Ventricular Tachycardia (Polymorphic)
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Ventricular Tachycardia (Monomorphic)
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3rd degree heart block (3rd degree AV block)
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1st degree atrioventricular block (1st degree AV block)
Regular rhythm, QRS narrow, but PR interval prolonged (>0.2).
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Supraventricular tachycardia
Rhythm: reg; HR: fast (150-250); P wave merged w/ T wave. PR, QRS nrml.
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Sinus bradycardia
Rhythm: reg; HR <60. P waves - present. PR int = wnl; QRS =narrow.
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Sinus bradycardia
Rhythm: reg; HR <60. P waves - present. PR int = wnl; QRS =narrow.
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Sinus tachycardia.
Rhythm: reg; HR > 100; P wave present. PRi: nrml. QRS narrow.
This is sinus tachycardia. For sinus tachycardia, the rhythm will be regular, with heart rate > 100 bpm. The P-waves will be normal but may be buried in the T-wave if the rate is very fast. The PR interval will be normal (0.12-0.20 sec), and the QRS complex will usually be normal. (0.06-0.10 sec). For adults, sinus rhythm rates typically will not exceed 150/min.
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Atrial Fibrillation
Rhythm: irreg; (-) P wave; (+) fine chaotic waves; Vent rate; variable.
This is atrial fibrillation. For atrial fibrillation, the rhythm will be irregular, and the P-waves will be characteristically absent and replaced with fine, chaotic waves. The ventricular rate is usually variable and may be slow, normal or rapid. Patients with symptoms will usually have a rapid ventricular rate. The PR interval will be absent, and the QRS complex is typically normal but can be widened in certain cases.
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Ventricular Tachycardia (Polymorphic)
Rhythm: regular; HR >150/min. (-) P wave; wide QRS (>.1sec).
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Atrial Flutter
This is atrial flutter. Atrial flutter can be regular or irregular. For atrial flutter, the atrial rate is typically extremely fast. (250-350 bpm). The ventricular rate is typically slower than the atrial rate. Saw-toothed flutter waves are usually seen instead of a single P-wave. The PR interval will not be measurable and the QRS is typically normal (0.06-0.10 sec).
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1st degree AV block
This is first-degree heart block. For first-degree heart block, the rhythm is regular. The PR interval will be prolonged at > 0.2. The QRS complex will usually be normal. First-degree heart block indicates slowed but not blocked conduction through the AV node.
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Asystole
This is asystole. For asystole, there is no discernible electrical activity on the ECG monitor. The isoelectric line may also have very light and intermittent deviation away from the baseline. When asystole is present, there may be intermittent agonal rhythms which will usually have a wide and bizarre form.
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2nd-degree AV Block Type II (Mobitz II)
This is second-degree heart block type II. For second-degree heart block type II, the ventricular rhythm will be irregular due to intermittent dropped QRS complexes. The atrial rhythm will be regular. The P-waves will look normal, and there will be more P-waves than QRS complexes. The PR interval will be normal or prolonged when a P-wave is followed by a QRS complex. The QRS complex will usually be normal or wide.
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2nd degree AV Block Type I (Mobitz I or Wenckebach)
This is second-degree heart block type I. For second-degree heart block type 1, the PR interval becomes progressively longer until finally there will be a dropped QRS complex. Then the cycle will repeat. The P-waves will be regular. The width of the QRS complex is usually normal (0.06-0.10 sec). (**Remember: longer, longer, longer, drop.)
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3rd degree atrioventricular block
This is third-degree heart block. For third-degree heart block, the rhythm will be regular, but atrial and ventricular rhythms are disassociated from one another. The atrial rate will usually be normal and faster than the ventricular rate. The P wave will be normal but may be missing if the atrial impulse occurs at the same time as ventricular firing. The P-wave will be buried in the QRS complex. The PR interval is not measurable since the atria and ventricles are completely disassociated. The QRS complex is typically normal, but can be wide.
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Ventricular Fibrillation
This is fine ventricular fibrillation. For ventricular fibrillation, the rhythm will be chaotic and wavy, with an unmeasurable heart rate. P-waves and QRS complexes are absent. Typically, this chaotic wavy line with varying amplitude will be the defining characteristic of ventricular fibrillation. It is possible that this could be asystole. When in doubt treat as ventricular fibrillation.
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Supraventricular Tachycardia (SVT)
This is supraventricular tachycardia (SVT). For SVT, the rhythm will be regular, and the heart rate will be fast (150-250 bpm). The P wave will typically be merged with t wave. If measurable, the PR interval will be normal (0.12 sec). The QRS complex will usually be normal (.10 sec).
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1st degree AV block.
This is first-degree heart block. For first-degree heart block, the rhythm is regular. The PR interval will be prolonged at > 0.2. The QRS complex will usually be normal. First-degree heart block indicates slowed but not blocked conduction through the AV node.
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Normal Sinus Rhythm
This is normal sinus rhythm. For normal sinus rhythm, the rhythm will be regular, and the rate will be 60-100/min. A P-wave will come before each QRS complex. The PR interval will be normal (0.12-0.20 sec), and the width of the QRS complex will typically be normal (0.06-0.10 sec).
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Ventricular Tachycardia (Polymorphic)
This is ventricular tachycardia. For ventricular tachycardia, the rhythm is regular, and the heart rate will typically be >150/min. The P waves will be absent and therefore, there will be no PR interval. The QRS will usually be wide (>0.10 sec). This particular rhythm happens to be polymorphic VT.
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3rd-degree Atrioventricular (AV) Block
This is third-degree heart block. For third-degree heart block, the rhythm will be regular, but atrial and ventricular rhythms are disassociated from one another. The atrial rate will usually be normal and faster than the ventricular rate. The P wave will be normal but may be missing if the atrial impulse occurs at the same time as ventricular firing. The P-wave will be buried in the QRS complex. The PR interval is not measurable since the atria and ventricles are completely disassociated. The QRS complex is typically normal, but can be wide.
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1st degree atrioventricular (AV) block
This is first-degree heart block. For first-degree heart block, the rhythm is regular. The PR interval will be prolonged at > 0.2. The QRS complex will usually be normal. First-degree heart block indicates slowed but not blocked conduction through the AV node.
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Hyperacute anteroseptal STEMI
ST elevation and hyperacute T waves in V2-4
ST elevation in I and aVL with reciprocal ST depression in lead III
Q waves are present in the septal leads V1-2
These features indicate a hyperacute anteroseptal STEMI
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Supraventricular Tachycardia (SVT)
This is supraventricular tachycardia (SVT). For SVT, the rhythm will be regular, and the heart rate will be fast (150-250 bpm). The P wave will typically be merged with t wave. If measurable, the PR interval will be normal (0.12 sec). The QRS complex will usually be normal (.10 sec).
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Sinus bradycardia
This is sinus bradycardia. For sinus bradycardia, the rhythm is regular, with a heart rate that will be < 60/min. The P-waves will be normal. The PR interval will be normal (0.12-0.20 sec), and the QRS complex is typically normal (0.06-0.10 sec).
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2nd degree atrioventricular (AV) block (Mobitz Type I or Wenckebach)
This is second-degree heart block type I. For second-degree heart block type 1, the PR interval becomes progressively longer until finally there will be a dropped QRS complex. Then the cycle will repeat. The P-waves will be regular. The width of the QRS complex is usually normal (0.06-0.10 sec). (**Remember: longer, longer, longer, drop.)
Identify this EKG strip.
Sinus Tachycardia
This is sinus tachycardia. For sinus tachycardia, the rhythm will be regular, with heart rate > 100 bpm. The P-waves will be normal but may be buried in the T-wave if the rate is very fast. The PR interval will be normal (0.12-0.20 sec), and the QRS complex will usually be normal. (0.06-0.10 sec). For adults, sinus rhythm rates typically will not exceed 150/min.
Identify this EKG Strip.
Atrial Fibrillation
This is atrial fibrillation. For atrial fibrillation, the rhythm will be irregular, and the P-waves will be characteristically absent and replaced with fine, chaotic waves. The ventricular rate is usually variable and may be slow, normal or rapid. Patients with symptoms will usually have a rapid ventricular rate. The PR interval will be absent, and the QRS complex is typically normal but can be widened in certain cases.
Identify this EKG strip.
3rd degree atrioventricular (AV) block
This is third-degree heart block. For third-degree heart block, the rhythm will be regular, but atrial and ventricular rhythms are disassociated from one another. The atrial rate will usually be normal and faster than the ventricular rate. The P wave will be normal but may be missing if the atrial impulse occurs at the same time as ventricular firing. The P-wave will be buried in the QRS complex. The PR interval is not measurable since the atria and ventricles are completely disassociated. The QRS complex is typically normal, but can be wide.
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2nd degree atrioventricular (AV) block (Mobitz Type II)
This is second-degree heart block type II. For second-degree heart block type II, the ventricular rhythm will be irregular due to intermittent dropped QRS complexes. The atrial rhythm will be regular. The P-waves will look normal, and there will be more P-waves than QRS complexes. The PR interval will be normal or prolonged when a P-wave is followed by a QRS complex. The QRS complex will usually be normal or wide.
Identify this EKG strip.
Atrial Flutter
This is atrial flutter. Atrial flutter can be regular or irregular. For atrial flutter, the atrial rate is typically extremely fast. (250-350 bpm). The ventricular rate is typically slower than the atrial rate. Saw-toothed flutter waves are usually seen instead of a single P-wave. The PR interval will not be measurable and the QRS is typically normal (0.06-0.10 sec).
Identify this EKG strip.
Ventricular Fibrillation
This is ventricular fibrillation. For ventricular fibrillation, the rhythm will be chaotic and wavy, with an unmeasurable heart rate. P-waves and QRS complexes are absent. Typically, this chaotic wavy line with varying amplitude will be the defining characteristic of ventricular fibrillation.
Identify this EKG strip.
Supraventricular Tachycardia
The term supraventricular tachycardia (SVT) refers to any tachydysrhythmia arising from above the level of the Bundle of His, and encompasses regular atrial, irregular atrial, and regular atrioventricular tachycardias
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Atrial Fibrillation
Irregularly irregular ventricular rate without visible P waves
- Irregularly irregular rhythm
- No P waves
- Absence of an isoelectric baseline
- Variable ventricular rate
- QRS complexes usually < 120ms, unless pre-existing bundle branch block, accessory pathway, or rate-related aberrant conduction
- Fibrillatory waves may be present and can be either fine (amplitude < 0.5mm) or coarse (amplitude > 0.5mm)
- Fibrillatory waves may mimic P waves leading to misdiagnosis
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Atrial Fibrillation
- Irregular ventricular response
- No evidence of organised atrial activity
- Fine fibrillatory waves seen in V1
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Atrial Flutter with 3:1 block
- Narrow complex tachycardia
- Regular atrial activity at ~300 bpm
- Loss of the isoelectric baseline
- “Saw-tooth” pattern of inverted flutter waves in leads II, III, aVF
- Upright flutter waves in V1 that may resemble P waves
- Ventricular rate depends on AV conduction ratio (see below)
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2nd degree Atrioventricular Block Mobitz Type I (Wenckebach AV block)
- Progressive prolongation of the PR interval culminating in a non-conducted P wave
- PR interval is longest immediately before the dropped beat
- PR interval is shortest immediately after the dropped beat
Dispatched to a 61 y.o. F in a rural community c/o palpitations and dizziness since awakening. GCS 15. HR 190, BP 75/50. Identify this EKG strip.
61 y.o. F BIBEMS c/o palpitations and dizziness since awakening. GCS 15. HR 190, BP 75/50. Per protocols, you cardiovert the patient. A repeat EKG was obtained. Identfiy this EKG strip.
Wolff-Parkinson-White (WPW) pattern
- Sinus rhythm, rate 90 bpm
- Normal P wave axis, persistent right axis deviation
- PR interval is relatively short at ~120ms, and there are broad QRS complexes with a slurred upstroke to the QRS complex – the delta wave
- Dominant R wave in V1 – this is associated with a left-sided AP and is sometimes termed a Type A Wolff-Parkinson-White (WPW) pattern
- Negative delta wave in aVL simulates the Q waves of lateral infarction – this is known as the “pseudo-infarction pattern”
- Tall R waves in right precordial leads can mimic right ventricular hypertrophy (RVH). These changes are due to pre-excitation and do not indicate RVH.
Dispatched to a female down at a local office building. Arrived on scene to find a 40 year old female with past medical history of seizures who had multiple episodes of syncope for 1 week. While seated, she feels lightheaded and unresponsive, with the episode lasting one minute. She was awake, protecting her airway, but was pale, cool, and diaphoretic. She did not appear to be in respiratory distress. Pulses were present. A rhythm strip was obtained.
Polymorphic Ventricular Tachycardia
Dispatched to a female down at a local office building. Arrived on scene to find a 40 year old female with past medical history of seizures w/o h/o prolonged QT who had multiple episodes of syncope for 1 week. While seated, she feels lightheaded and unresponsive, with the episode lasting one minute. She was awake, protecting her airway, but was pale, cool, and diaphoretic. She did not appear to be in respiratory distress. Pulses were present. She converted spontaneously while on scene. She was then emergently transported to the ER for evaluation. A repeat EKG was obtained on arrival (reported QT interval was 445 ms - is this Torsades de Pointes?
No. This is Polymorphic VT.
- Take Home Point: Torsades de Pointes is polymorphic ventricular tachycardia AND a prolonged QT intervanl (congenital or acquired).
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Sinus Tachycardia
- Rate: 100-150 BPM
- PRI: .12-.20 sec
- QRS: < .12
- QT: < .40
- Rhythm: Regular
- Source of pacer: SA Node
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Sinus Tachycardia
- Rate: 100-150 BPM
- PRI: .12-.20 sec
- QRS: < .12
- QT: < .40
- Rhythm: Regular
- Source of pacer: SA Node
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Supraventricular Tachycardia
Rate: > 150 BPM
PRI: Usually < .12 sec
QRS: Narrow, < .12 sec
QT: < .40 sec
Rhythm: Regular
Source of pacer: Atrial re-entry current
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Sinus Tachycardia
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Ventricular Fibrillation
- bizarre, irregular, random waveform
- no clearly identifiable QRS complexes or P waves
- wandering baseline
55 year old male presented to ER with palpitations. While in the ER, he received adenosine, and the following rhythm strip was noted. Identify the rhythm strip.
Atrial Flutter
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Atrial Flutter with Variable Block
Identify this 12-Lead EKG.
Normal Sinus Rhythm
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Atrial Fibrillation
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Wide Complex Tachycardia
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Sinus Rhythm with premature atrial contraction
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Atrial Fibrillation w/ HR of 60.
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Non-sustained Ventricular Tachycardia
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Supraventircular Tachycardia
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Supraventricular Tachycardia
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Normal Sinus Rhythm
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Atrial fibrillation @ ~90 bpm with transient conduction delay and monomorphic PVCs.
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Normal sinus rhythm with monomorphic premature atrial contractions
28 year old hirsute male with PMHx of polysubstance abuse, anxiety brought in after an altercation with his girlfriend. Patient remained uncooperative with EMS en route. Identify this EKG strip.
Sinus tachycardia (with leads falling off)
54 year old male presented to the ER with chest painand diaphoresis. The nurse practitioner administers sublingual nitroglycerin prior to obtaining an EKG, and the patient’s BP drops to 80/50. Identify the EKG.
Inferior Wall MI w/ RV infarction
EMS arrives on scene to find a 59 year old female c/o dizziness and unsteady gait that started a day ago. EMS was called because she was now found lethargic and confused by family. Past medical history notable for diabetes and HTN. Medications include insulin amlodipine, and gabapentin. Vtial signs HR 48, BP 224/100, RR 18, T 36.8 C. EKG obtained. Identify this EKG.
Sinus bradycardia with prolonged QT interval
EMS arrives on scene to find a 59 year old female c/o dizziness and unsteady gait that started a day ago. EMS was called because she was now found lethargic and confused by family. Past medical history notable for diabetes and HTN. Medications include insulin amlodipine, and gabapentin. Vtial signs HR 48, BP 224/100, RR 18, T 36.8 C. She was immediately transported to the ER and evaluated. The patient soon had a change in mental status while a repeat EKG was taken. Identify this EKG.
Polymorphic Venrticular Tachycardia (Torsades de Pointes)
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Junctional Rhythm
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Sinus Bradycardia
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Asystole
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Ventricular Paced (V-paced) Rhythm
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Normal Sinus Rhythm
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Sinus Bradycardia
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Junctional Rhythm
- Junctional rhythm with a rate of 40-60 bpm
- QRS complexes are typically narrow (< 120 ms)
- No relationship between the QRS complexes and any preceding atrial activity (e.g. P-waves, flutter waves, fibrillatory waves)
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Acclerated Idioventricular Rhythm (with a HR of 70)
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Ventricular Paced (V-Paced) with Capture (HR 80)
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Monomorphic Ventricular Tachycardia
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Atrial Fibrillation
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Atrial Fibrillation
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Ventricular Fibrillation
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Junctional Rhythm (HR 50)
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3rd Degree AV Block (Complete Heart Block)
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3rd degree Atrioventricular (AV) Block (Complete Heart Block)
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3rd degree AV block
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1st degree AV Block
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1st degree AV Block
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3rd degree AV block (Complete AV Block)
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Sinus Tachycardia
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High-grade AV block
- Second degree heart block with a P:QRS ratio of 3:1 or higher, producing an extremely slow ventricular rate.
- Unlike 3rd degree heart block there is still some relationship between the P waves and the QRS complexes.
- High-grade AV block may result from either Mobitz I or Mobitz II AV block.
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2nd degree AV block (Mobitz II)
21 year old male presents to the Emergecy Department with acute onset palpitations that started 1 hour ago. Vital signs on arrival - BP 69/50, HR 190, RR 24, SpO2 92% RA, T 97.0, BGL 110. EKG strip is attached. What is the most appropriate intervention?
Synchronized Cardioversion
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Left anterior fascicular block
- Left axis deviation (usually -45 to -90 degrees)
- qR complexes in leads I, aVL
- rS complexes in leads II, III, aVF
- Prolonged R wave peak time in aVL > 45ms
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RBBB with LFPB and RAD
- Right axis deviation (RAD) (> +90 degrees)
- rS complexes in leads I and aVL
- qR complexes in leads II, III and aVF
- Prolonged R wave peak time in aVF
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Accelerated Juncitonal rhythm
ECG Features:
Narrow complex rhythm; QRS duration < 120ms (unless pre-existing bundle branch block or rate-related aberrant conduction)
Ventricular rate usually 60 – 100 bpm
Retrograde P waves may be present and can appear before, during or after the QRS complex. They are usually inverted in inferior leads (II, III, aVF), upright in aVR + V1
AV dissociation may be present with the ventricular rate usually greater than the atrial rate
There may be associated ECG features of digoxin effect or digoxin toxicity
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Idioventricular Rhythm
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Sinus Rhythm with PVCs
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Asystole
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3rd degree heart block
Severe bradycardia due to absence of AV conduction
The ECG demonstrates complete AV dissociation, with independent atrial and ventricular rates
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3rd Degree AV Block
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Left Anterior Fascicular Block
Left axis deviation (usually -45 to -90 degrees)
qR complexes in leads I, aVL
rS complexes in leads II, III, aVF
Prolonged R wave peak time in aVL > 45ms
Identify this EKG strip.
Left Anterior Fascicular Block
Left axis deviation (usually -45 to -90 degrees)
qR complexes in leads I, aVL
rS complexes in leads II, III, aVF
Prolonged R wave peak time in aVL > 45ms
